MedGem Indirect Calorimeter Coding Options

1 Medical necessity must be established in order for Indirect calorimetry to be considered for payer reimbursement. Individual payers develop their own criteria for medical necessity. Payers should be consulted for their : The MedGem measurement (CPT 94690) may not be considered medically necessary for asymptomatic overweight individuals. However, coverage potential is higher if there is an underlying medical need. The use of Indirect calorimetry is indicated for the following reasons: To determine the extent of abnormalities and the causative disease process. To determine the progression of the disease. To determine a course of therapy in the treatment of a particular to Center for Medicare Services (CMS), Indirect calorimetry is designed to evaluate the status of structural components of the lung in an Indirect overlapping way.

2 Medicare specifically excludes screening test for an asymptomatic patient, with or without high risk of lung disease. The following ICD-9-CM codes that support medical necessity by CMS Sleep Apnea, Hypoventilation Chronic Pulmonary Heart Heart Chronic Airway Obstruction (COPD) Lung involvement in other diseases classified Sleep Dyspnea and Respiratory Abnormalities, Shortness of HypoxemiaAlternative ICD-9-CM codes that may support medical necessity by private payers Hypothyroidism Metabolic Diabetes Mellitus Hypercholesterolemia Hyperlipidemia Cardiovascular DiseaseThe above codes are possible Coding Options for CPT 94690. Other Coding Options may apply based on a patient s diagnosis.

3 For a complete list of Coding Options and description, consult the current ICD-9-CM Oxygen uptake, expired gas analysis; rest, Indirect (separate procedure).Office Visits Note: Contact your payer for their Coding guidelines to determine if the MedGem measurement should be billed separately or in conjunction with an office Office or other outpatient visit for the evaluation and management of a new Office or other outpatient visit for the evaluation and management of an established Oxygen uptake, expired gas analysis; rest, Indirect (separate procedure).MNT Note: Contact your payer for their Coding guidelines to determine if the MedGem measurement should be billed separately or in conjunction with medical nutrition Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 Payer policies vary concerning Evaluation & Management Services.

4 The provider should clarify requirements pertaining to the MedGem measurement during the preauthorization process or prior to claim Payer policies vary concerning MNT and dietitian services. The provider should clarify requirements pertaining to the MedGem measurement during the preauthorization process or prior to claim customer/product assistance, please visit our website at or send email to ReimbursementCoding OptionsMedGem Indirect CalorimeterFollow us on:&For customer/product assistance, please visit our website at or send email to ReimbursementCoding OptionsMedGem Indirect CalorimeterQ. What is the MedGem Indirect Calorimeter ?The MedGem Indirect Calorimeter is a handheld, self-calibrating Calorimeter which allows for accurate measurement of oxygen uptake (VO2) to determine a patient s Resting Metabolic Rate (RMR).

5 Q. Should we obtain preauthorization for the MedGem measurement?Yes, we recommend preauthorization of the MedGem measurement. Preauthorization clarifies benefits and payment rates in advance, allowing you and your patient to make informed decisions about their care. The only notable exception to this general rule is Medicare. Traditional Medicare does not preauthorize medical procedures. You should verify the patient s insurance benefits as well as their current eligibility by calling the Customer/Member Services phone number indicated on the patient s insurance card. You may be asked to provide diagnosis and procedure code(s) at that time. See the reverse side of this card for possible Coding Options related to the payers no longer require preauthorization for outpatient procedures or for services under a specified dollar amount.

6 Instead, services are reviewed for medical necessity and coverage when the claim isreceived. Accordingly, we strongly recommend that the patient sign a Waiver of Financial Liability inthe event of a non-coverage or partial coverage CPT code 94690 is listed under the pulmonary section of the CPT book why would I use it for obese patients?The AMA CPT Information Services has verbally confirmed that CPT 94690 is an appropriate code for the MedGem measurement. If you feel the code does not accurately describe the procedure performed, you should contact the payer and discuss your concerns. In some cases, they may recommend use of an unlisted code. Coding is ultimately the decision of the physician and the payer and should appropriately reflect the procedure as documented in the patient s medical Will our claim be denied if we use an unlisted CPT code?

7 Not necessarily. Unlisted codes are used when a service or procedure provided is not described by existing CPT codes. The payer will review your claim individually and base their decision for payment on their coverage guidelines and the documentation submitted. Appropriate documentation will assist the payer in determining medical appropriateness for the procedure. We recommend submission of a SPECIAL REPORT with all unlisted claims. The SPECIAL REPORT should describe the nature, extent and need for the procedure as well as the time, effort and equipment necessary to perform the Which insurance companies are covering the MedGem measurement?It is difficult to make generalizations regarding insurance coverage as insurance plans vary and are specific to policies negotiated by the employer group.

8 However, if medical necessity exists, most insurance carriers including Medicare will consider coverage. The average reimbursed cost is between $ and $ What if the payer denies coverage for 94690 because the code is limited to pulmonaryfunction tests or the diagnosis is not of a pulmonary nature?We recommend challenging the denial based on medical necessity and the AMA CPT Information Services confirmation of CPT Coding . If this is unsuccessful, ask the payer if they prefer the claim be resubmitted with an alternative code which they five-digit codes, descriptions, two-digit modifiers and other data are copyright 2003 American Medical Association. All rights reserved. This Coding list is not all-inclusive and is not intended to represent all Coding Options .

9 Coding of diagnoses and procedure codes is dependent on documentation in the patient s medical record. The information in this document is provided as a guide for Coding procedures and services for the Microlife MedGem Indirect Calorimeter . It is not intended to increase or maximize reimbursement by any payer. This information is intended to assist providers in accurately obtaining coverage and reimbursement for health care services. Providers assume full responsibility for all reimbursement decisions or actions. We strongly suggest that you consult your payer organizations with regard to local coverage and reimbursement policies. Procedures done concurrently should be coded according to the procedures done. August 2008 2010 Microlife Medical Home Solutions, Inc.

10 All rights reserved. Microlife and WatchWT are registered trademarks of Microlife Corp. MedGem is a registered trademark of Microlife Medical Home Solutions, Inc. Art P/N: 603-0328-01-E.